Provider Demographics
NPI:1710105333
Name:C. GLEN FERGUSON D.O. P.C.
Entity Type:Organization
Organization Name:C. GLEN FERGUSON D.O. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:C.
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-296-5840
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81002-0570
Mailing Address - Country:US
Mailing Address - Phone:719-296-5840
Mailing Address - Fax:719-542-0746
Practice Address - Street 1:1615 BONFORTE BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1602
Practice Address - Country:US
Practice Address - Phone:719-296-5840
Practice Address - Fax:719-542-0746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01172055Medicaid
FE03792OtherBCBS
CO01172055Medicaid
COC3792Medicare PIN